Polypharmacy: when the prescription becomes part of the problem

Polypharmacy: when the prescription becomes part of the problem

Why older people need comprehensive reassessment—not simply another prescription for each new symptom

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Gerry Gajadharsingh writes:

“This weekend’s Sunday Times investigation into polypharmacy should concern every clinician, patient and family caring for an older person. The newspaper reports that potentially avoidable adverse drug reactions are contributing to falls, dizziness, low blood pressure, irregular heart rhythms, confusion and emergency hospital admissions on a very large scale.

This is not a new concern. In June 2022, I wrote on The Health Equation website about the danger of a ‘pill for every ill’, particularly when prescriptions accumulate over many years without adequate review. Four years later, the scale of the problem appears even clearer. New national research, based on 5.8 billion medicines dispensed to 52.6 million people in England, found that approximately 42 per cent of 70-year-olds had received five or more concurrent medicines within a three-month period.

However, the number of tablets alone does not tell us whether prescribing is good or bad. Many medicines are essential, effective and life-preserving. The real clinical question is whether every medicine remains appropriate for this particular person, at this stage of life, at the present dose, in combination with everything else they take—and in the context of their current kidney function, blood pressure, mobility, cognition, nutrition and priorities.

A recent patient brought this into sharp focus

I was recently asked to assess an older patient in her mid-eighties who was experiencing dizziness, unsteadiness, breathlessness and concern about falling. She felt that these problems were simply part of getting older because many of her friends had similar complaints. Yet symptoms that are common in later life are not necessarily inevitable, and they should not automatically be dismissed as ageing.

In patients with complex dizziness, it is also not unusual to find significant neck and wider musculoskeletal dysfunction, particularly where there has been longstanding pain, altered gait, reduced mobility or a loss of confidence in movement. Cervical proprioceptive information is integrated with visual and vestibular information to help regulate head position, posture and balance. Restriction, muscular tension or altered sensorimotor input from the neck may therefore contribute to disequilibrium or unsteadiness and may become part of a self-reinforcing cycle: dizziness reduces movement confidence, guarded movement increases stiffness and deconditioning, and deteriorating gait further challenges balance. This does not mean that dizziness should simply be labelled as coming from the neck. Cervical dysfunction should be considered as one potentially contributing component while vestibular, neurological, cardiovascular, medication-related and other important causes are appropriately assessed.

Understanding her situation took many hours. It required a detailed review of her previous results and medical history; a full clinical examination; capnography and other physiological assessment; updated blood and urine investigations; and careful diaries recording when she took each medicine, when she took her thyroid medication, and how her blood pressure changed at different times of day and with changes of posture. I then brought the information together in a report for a consultant geriatrician.

Initially, she strongly disliked my suggestion of a geriatric opinion. She thought I was implying that she should go into a care home. I was suggesting nothing of the sort. A geriatrician is a physician specialising in the complex interaction of illness, medication, function and resilience in older people. The purpose of referral was to help her remain as well, safe and independent as possible—not to take independence away.

Her case illustrates why a brief appointment focused on one isolated symptom may be insufficient. Dizziness might lead to a drug for dizziness; pain to another analgesic; poor sleep to a sedative; bladder symptoms to another prescription. Yet the better question may be whether the symptoms are connected, whether one medicine is worsening another problem, or whether the person’s physiology has changed since the prescription was first issued.

The lack of continuity of care was itself part of the problem. Over time, she had made multiple visits to her general practice and had been seen by several different GPs. Each consultation may have addressed the immediate symptom or concern, but no single clinician had the continuity—or sufficient time—to reconstruct the full chronology, review the cumulative effect of her medicines, compare her blood-pressure and medication-timing diaries, undertake a comprehensive clinical assessment and physical examination, and ask whether apparently separate symptoms might actually be connected.

This should not be interpreted as criticism of the individual doctors involved. Most GPs are working conscientiously within a system of short appointments, rising complexity, fragmented records and relentless demand. The system is organised largely around episodic consultations and individual diagnoses; it does not routinely provide the protected time required for careful longitudinal assessment of an older person with several interacting problems. Individual doctors may be doing their very best, while the structure in which they work makes whole-person synthesis exceptionally difficult.

The prescribing cascade

A prescribing cascade occurs when the adverse effect of one medicine is interpreted as a new medical condition and treated with another medicine. For example, a blood-pressure drug may contribute to ankle swelling; a diuretic may then be added; the combination may increase urinary frequency, dehydration, postural hypotension and falls risk. Each prescription may have appeared rational when considered alone, while the overall result becomes harmful.

Ageing can also change the balance between benefit and risk. Kidney and liver function may decline, body composition changes, blood-pressure regulation becomes less robust and the nervous system may become more sensitive to sedative or anticholinergic effects. A dose tolerated years ago may no longer be tolerated now. This is why repeat prescribing should never become automatic rubber-stamping.

Polypharmacy viewed through the Seven Regulatory Systems

Within my Integrated Regulatory Systems Framework (IRSF), the seven systems do not operate independently. They communicate continuously, and medicines may help one system while placing additional load on another.

Respiratory: Sedatives, opioid analgesics and combinations of centrally acting drugs may suppress respiratory drive. Breathing dysfunction can also contribute independently to dizziness, breathlessness and altered autonomic regulation, which is why capnography may add useful physiological information.

Neural: Confusion, slowed reactions, poor balance, sleepiness and dementia-like symptoms may reflect cumulative central nervous system or anticholinergic effects. Neural regulation also includes the autonomic responses needed to maintain blood pressure when standing.

Endocrine: Thyroid, diabetic and steroid medicines require interpretation alongside current symptoms, biochemistry, dose and timing. Hormonal physiology and medication needs may change with age, illness, weight loss or altered absorption.

Immune and inflammatory: Anti-inflammatory drugs may relieve pain but can increase gastrointestinal, renal or cardiovascular risk in susceptible people. Long-term corticosteroid exposure can affect immunity, glucose regulation, muscle and bone.

Metabolic: Renal and hepatic function influence how medicines are cleared. Dehydration, poor nutrition and electrolyte disturbance can turn a previously stable prescription into a source of toxicity or instability.

Musculoskeletal: Weakness, pain, cervical restriction, altered proprioceptive input, reduced mobility and impaired balance may all contribute to complex dizziness and increase the consequences of postural hypotension. Altered gait and fear of falling can reduce movement further, promoting stiffness and deconditioning. A fall may then lead to injury, hospital admission and additional medication.

Circulatory: Antihypertensives, diuretics and rate-controlling drugs may interact with hydration, renal function, heart rhythm and postural blood-pressure control. Sitting blood pressure alone may miss clinically important changes on standing.

What a meaningful medication review should ask

• Why was each medicine started, and is that indication still present?
• Is there clear evidence that it is still providing benefit for this individual?
• Has kidney or liver function, weight, nutrition, cognition or frailty changed?
• Could a medicine—or the interaction between several medicines—explain a new symptom?
• Are doses and timings correct, and is the patient actually taking the medicines in the way the record assumes?
• Are there duplicate drugs, over-the-counter products or supplements that have not been considered?
• Can any medicine be reduced or withdrawn safely, gradually and with appropriate monitoring?
• What matters most to the patient: longevity, symptom control, alertness, mobility, independence or avoiding falls?

Deprescribing is clinical treatment—not therapeutic neglect

Deprescribing does not mean suddenly stopping medicines, and patients should never alter prescribed treatment without professional guidance. Some medicines cause withdrawal effects or a rebound in symptoms if stopped abruptly. Others remain essential despite inconvenience or potential adverse effects.

Good deprescribing is a structured, shared clinical process. It involves identifying the least useful or most hazardous medicine, changing one variable at a time where possible, monitoring the response and being prepared to reinstate treatment if necessary. It requires time, judgement and communication between the patient, GP, pharmacist, specialists and family or carers.

The Sunday Times campaign calls for better education in prescribing and deprescribing, annual medication reviews for frail older people taking ten or more medicines, and a substantial increase in consultant geriatricians. These are sensible ambitions. But a review must be more than a tick-box exercise: it needs sufficient time to understand the person behind the prescription list.

The wider lesson

Modern medicine is exceptionally good at developing treatments for individual diseases. The difficulty arises when a person has several diagnoses, sees several clinicians and accumulates treatments based on separate guidelines. The patient becomes the meeting point for all those decisions, yet no one may have been given enough time to examine the combined effect.

This is precisely where integrated clinical reasoning matters. We must ask not only ‘Which disease does this patient have?’ but also ‘How is this person regulating, adapting and functioning as a whole?’ The aim is not to reject medication, but to use it more intelligently—alongside nutrition, hydration, breathing regulation, movement, balance work, sleep support and other appropriate non-pharmacological measures.

For older people with dizziness, falls, confusion, low blood pressure or a sudden decline in function, the medication list should be regarded as part of the examination. Sometimes the next best treatment is not another tablet. It is the time, curiosity and clinical courage to reconsider the tablets already there.”

Clinical Disclaimer

This article is intended for educational and informational purposes only. It does not constitute medical advice and should not replace individual consultation with a qualified healthcare professional.

Supporting references

GP’s increase side-effects risks with a pill for every ill (17 June 2022)

Dale CE et al. Patterns of medication use across society from national primary care dispensing data. Nature Health. 2026;1:967–978. Open-access research article

Seemungal BM et al. The Bárány Society position on ‘Cervical Dizziness’. Journal of Vestibular Research. 2022;32(6):487–499. Open-access position paper

Main article

Mixing pills sends 1,000 elderly people a day to A&E

Our investigation shows millions are at risk of avoidable reactions to overprescribed drugs

Shaun Lintern, Health Editor | The Times | 6 September 2026

Read the original article online

An over-prescribing epidemic is leading to thousands of elderly people being admitted to hospital suffering reactions to cocktails of medicines.

A Sunday Times investigation has found doctors are routinely giving out potentially harmful levels of medication to elderly patients, leading to falls, low blood pressure, dizziness and irregular heartbeats.

Almost eight million people in the UK are at risk of medical side-effects because they are being prescribed five or more drugs to take daily. About 2.2 million take ten drugs a day, a study published earlier this year reveals.

Taking more than five medicines is defined as “polypharmacy”, as this is the point at which the risk of side-effects increases. It is particularly dangerous in patients considered to be frail and often living with mobility issues.

The Sunday Times is launching a campaign calling on the NHS and government to stop the prescription trap that is harming elderly patients. Our three calls for action are:

All medical students must learn the risks of mixing medicines and receive training for how and when to de-prescribe

The NHS should ensure that anyone over 65 who is considered frail and is taking 10 or more medications is invited for an annual review of their drug regimen

1,850 more geriatricians must be trained by 2030 to ensure there is one doctor for every 500 patients aged 85 and over

Analysis of NHS data reveals that as many as 1,000 elderly patients a day are admitted for emergency care in hospital after suffering a preventable reaction to a drug they are taking. Coroners have also warned about the dangers of polypharmacy contributing to deaths.

Studies blame the over-prescription on systemic failures in the NHS. Clinical guidelines mean doctors often treat patients for single conditions while time constraints and shortages of appointments mean they cannot do long, complex evaluations that older people need. Fragmented care between hospitals, homes and GPs means medications can pile up, and sometimes side-effects of one drug are misdiagnosed as a new condition.

Drugs that were properly prescribed decades earlier for complaints such as high blood pressure can become dangerous as a person ages and their body reacts differently. As more drugs accumulate, they can interact, causing dementia-like symptoms.

However, doctors have said that for many elderly people, the medications they are prescribed will be vital and necessary and that no one should stop taking them without first speaking to their GP or a specialist doctor.

The crisis of over-prescribing costs the NHS an estimated £2.21 billion a year, according to figures published by the University of Southampton.

‘Dad became a different person’

For more than two decades, Peter Eustace, 96, has swallowed his 400mcg tablet of tamsulosin every day. The drug was meant to help shrink his prostate.

However, Eustace, who has severe Alzheimer’s, had his entire prostate removed after cancer in 2001. For 25 years he was taking a drug he no longer needed, that can cause dizziness and low blood pressure. The retired print worker from East Yorkshire was taking eight other drugs in total, including a statin and ramipril for high blood pressure.

After a series of falls Eustace was referred for a specialist geriatric review carried out by the geriatrician Dr Daniel Harman in July. Harman discovered the prostate drug error and found Eustace was taking three other medications he no longer needed, including the statins and ramipril. He died on Wednesday.

“The prostate drug is quite unusual. But the others are commonplace,” Harman said. “The statin was possibly causing harm. The ramipril is potentially serious and I think it’s causative. I suspect it’s the reason he was falling.”

Ramipril is taken by approximately six million people and, like most blood pressure medications, its effect can be stronger as someone ages.

Eustace’s daughter Heather Crosby, 64, said her father’s decline had initially accelerated after a fall in April 2024 that left him in the Hull Royal Infirmary for a week. “He was in a hell of a state when he came home,” she said. “He was a different person”.

Crosby said she queried her father’s prostate medication with his GP practice but was told it was needed.

“My mum Margaret just daily puts his drugs in a dish and my dad just takes them, no question,” Crosby said. “We trusted what we were told by the NHS. They have just kept rubber stamping the same prescriptions year in, year out, without thinking of side-effects or the lack of benefit that Dad was going to get out of them.”

Most 90-year-olds are prescribed at least five drugs a day

Harman is part of a team at the dedicated Jean Bishop Integrated Care Centre, in Hull, providing geriatric assessments for frail elderly people.

“Medications that started for the right reasons, years later are causing more harm than good. In hospital, we know we will see one in six people on a ward and it’s their medications that have put them in hospital. I reflect on this a lot, it’s deeply frustrating,” he said.

For many elderly people, the medications they are prescribed will be vital. No one should stop their medications without first speaking to their GP or specialist doctor.

Leading clinicians are now calling for doctors to receive better training in the art of de-prescribing or stopping drugs. They also want to see more specialist geriatricians — experts in the care of the elderly — and medication reviews for elderly patients.

Jugdeep Dhesi, 56, the president of the British Geriatrics Society and a consultant geriatrician at Guy’s and St Thomas’ NHS Foundation Trust in London, said: “The more tablets that you take, the more likely there are interactions, and this can happen more the older you are.”

She added: “We have got these statistics and evidence coming at us, and we’re all really worried about it, but the system just keeps on looking down and thinking if we just carry on doing the same thing, it’ll be OK. It won’t.”

She is among experts who wrote to medical regulators including the General Medical Council as well as Professor Sir Chris Whitty, England’s chief medical officer, to warn of the “threat to patient safety”.

Painkillers linked to bad reactions

Studies in the British Medical Journal found have two thirds of admissions to hospitals that were related to medicine the patient was taking are thought to be preventable.

Many of the common drugs given to elderly people can have cumulative side-effects and cause severe symptoms.

For example, pills to reduce blood pressure — such as ramipril or amlodipine — can affect an older person more, leading to dangerous drops in blood pressure and falls.

Water tablets, such as furosemide, to reduce swelling that is sometimes a side-effect of amlodipine, can make the risk of falls even worse.

Painkillers such as ibuprofen are poorly tolerated by older people and linked to as many as 30 per cent of hospital medicine reactions with other drugs. Medicines to control the bladder, gastrointestinal system and even regular antihistamine tablets can interact with each other and have a powerful combined effect on an elderly person who may have taken them for many years without issue.

In some cases side-effects of medication can appear dementia-like. People are left confused, have difficulty walking and suffer unexplained falls and collapses.

Scale of the problem and signs of progress

A landmark study by clinicians at the University of Liverpool, published in Nature Health in June, revealed the full extent of the polypharmacy crisis.

In December 2024, more than six million people over 60 in England were on five or more drugs, 1.8 million were taking ten or more and 85,000 were regularly consuming 20 or more medications.

By the age of 70, more than two fifths of all patients in England were taking five or more drugs.

Separate research has shown someone who takes ten or more medicines is four times more likely to be admitted to hospital because of toxic interactions between medications, causing sudden drops in blood pressure, severe dizziness, or confusion.

Coroners have repeatedly highlighted the problems caused by polypharmacy following the deaths of patients who suffered falls or other serious side-effects.

Edward Cowey died from injuries after several falls at the Royal Derby Hospital in 2020. He was taking 12 medications for various health conditions which combined to increase his risk of a fall. Responding to the coroner, NHS England accepted that polypharmacy increased risks for these types of patients.

Jacqueline Campbell, 56, died in June 2022 after being overprescribed multiple drugs to manage chronic back pain for 20 years. The coroner found the drugs had collectively depressed her central nervous system, causing respiratory failure and death.

GPs are meant to carry out proactive checks on their patients classed as living with frailty. This can include a medication review or falls assessment to help identify problems before they develop. Patients are identified using a frailty index tool which looks at those over 65 who have issues with their mobility, movement or medicines to determine where they are on the frailty spectrum. The British Geriatrics Society has said frail patients may be more susceptible to side-effects from polypharmacy.

But despite this only 17 per cent of over-65s received a frailty check in 2024-25, and of 226,000 patients with severe frailty, only 16 per cent actually had a medication review.

There are about 1,600 geriatricians in England but the British Geriatrics Society estimates there are 2,000 fewer than needed. This shortage means comprehensive assessments cannot be carried out, putting pressure on GPs.

Despite the concerns NHS England has scrapped a £750,000 training programme for NHS staff aimed at trying to reduce the number of unnecessary prescriptions.

Progress is being made. The NHS England ten-year plan proposed services in local neighbourhoods, rather than hospitals, because it allows more individualised care. New tools have been developed to help GPs identify frail patients for review by automatically scanning patient data and records.

However, medical students get only four to eight weeks of training in geriatric medicine across the whole five years of their education, and once working in the NHS as trainees they get only a maximum of six months.

Dhesi, whose geriatric service at Guys’ and St Thomas’ Hospital tries to proactively target frail elderly patients, said: “We have to reform the training. We just haven’t thought hard enough about how we need to transform our health and social care services to meet the needs of the growing older population.”

A new national plan for the care of the frail elderly is due to be published in January. This will set modern standards for care of the elderly, including prescription of medication.

An NHS spokesperson said: “We know we need to do more to meet the needs of our ageing population better and that’s why we have made it clear to NHS organisations what the best interventions are to provide effective community support for frail people through new guidance, such as ensuring their care plans involve regular medication reviews so that only medicines that are clinically appropriate are prescribed.”

Source note: Article by Shaun Lintern, Health Editor, originally published in The Times. The article text above has been retained in full from the copy supplied for ease of clinical reference. Copyright remains with Times Media Limited and the original author.